Making Integrated Care WorkMI Primary Care Association

September 28, 2012

Laura Galbreath, MPP

Director, Center for Integrated Health Solutions

Agenda

-About the Center for Integrated Health Solutions

-Lessons Learned from Grantees and Others• PC/BH Partnership - Communication• Workforce Development• Health Homes• Health Behavior Change• Operations and Administration• Financing and Billing

About the Center In partnership with Health & Human Services (HHS)/Substance Abuse and Mental Health Services Administration (SAMHSA), Health Resources and Services Administration (HRSA).

Goal: To promote the planning, and development and of integration of primary and behavioral health care for those with serious mental illness and/or substance use disorders and physical health conditions, whether seen in specialty mental health or primary care safety net provider settings across the country.

Purpose: To serve as a national training and technical assistance center on the bidirectional

integration of primary and behavioral health care and related workforce development To provide technical assistance to PBHCI grantees and entities funded through HRSA

to address the health care needs of individuals with mental illnesses, substance use and co-occurring disorders

The Center for Integrated Health Solutions is dedicated to increasing the number of:

Individuals trained in specific behavioral health related practicesOrganizations using integrated health care service delivery

approachesConsumers credentialed to provide behavioral health related

practicesModel curriculums developed for bidirectional primary and

behavioral health integrated practiceHealth providers trained in the concept of wellness and behavioral

health recovery

Center for Integrated Health SolutionsTarget Populations

SAMHSA Primary & Behavioral Health Care Integration (PBHCI) Grantees HRSA Grantees General Public

Services Training and Technical Assistance Knowledge Development Prevention and Health Promotion/Wellness Workforce Development Patient Protection and Accountable Care Act Monitoring and Updates

Technical Assistance MenuIndividual Technical Assistance:

Phone consultations, e-mail, site visits

Group Learning Experiences: Learning Communities Webinars Trainings Practical Web-Based Resources (CIHS website, e-newsletter,

discussion boards)

Tools: Toolkits/Guidelines Training Curricula Fact Sheets

SAMHSA Primary and Behavioral Health Care Integration (PBHCI)

Grant Program

Program purpose:To improve the physical health status of people with

SMI by supporting communities to coordinate and integrate primary care services into publicly funded community-based behavioral health settings

Expected outcome:Grantees will enter into partnerships to develop or

expand their offering of primary healthcare services for people with SMI, resulting in improved health status

Population of focus:Those with SMI served in the public behavioral health

systemEligible applicants:

Community behavioral health agencies, in partnership with primary care providers

PBHCI Program

UT

AZ NM

WY

MT ND

SD

NE

KS

OK

TX LA

AR

MO

IA

MN

WIMI

IL IN

KY

WV

OH

MD

OR

CA

AKHI

NV

ID

WA

CO

NJ

DE

MA

NH

CT

VT

PA

NY

RI

ME

ALMS

TN

SC

NC

VA

FL

GA

DC

Central Region (2)9 Grantees

Midwest Region (4)15 Grantees

Northeast & Mid-Atlantic Region (5)17 Grantees

Southeast Region (3)9 Grantees

West Region (1)14 Grantees

SAMHSA PBHCI Learning Communities

West Region (1)

AK: Alaska Islands Community Services (III)AK: Southcentral Foundation (IV)CA: Alameda County Behavioral Health Care Services (II)CA: Asian Community Mental Health Services (III)CA: Catholic Charities of Santa Clara County (IV)CA: Glenn County Health Services Agency (III)CA: Mental Health Systems, Inc (I)CA: San Francisco Department of Public Health (IV)CA: San Mateo County Health System (III)CA: Tarzana Treatment Centers, Inc. (III)OR: Native American Rehabilitation Association of

the Northwest (II)WA: Asian Counseling and Referral Service (III)WA: Downtown Emergency Service Center (III)WA: Navos (IV)

Central Region (2)

AZ: CODAC Behavioral Health Services (I)CO: Mental Health Center of Denver (I)LA: Capital Area Human Services District (IV)OK: Central Oklahoma Community MH Center (I)OK: NorthCare Community Mental Health Center (III)TX: Austin-Travis County Integral Care (III)TX: Lubbock Regional MH & MR Center (II)TX: Montrose Counseling Center (II)UT: Weber Human Services (III)

Southeast Region (3)

FL: Apalachee Center, Inc(III)FL: Coastal Behavioral Healthcare (III)FL: Community Rehabilitation Center (III)FL: Lakeside Behavioral Healthcare (III)FL: Lifestream Behavioral Center (III)FL: Miami Behavioral Health Center (III)GA: Cobb/Douglas Community Services Board (III)SC: South Carolina State Department of Mental Health (III)VA: Norfolk Community Services Board (IV)

Midwest Region (4)

IL: Heritage Behavioral Health Center (III)IL: Human Service Center (I)IL: Trilogy, Inc(III)IN: Adult & Child Mental Health Center (III)IN: Centerstone of Indiana (II)IN: Health & Hospital Corporation of Marion County (IV)IN: Regional Mental Health Center (II)KY: Pennyroyal Regional MH/MR Board (I)MI: Washtenaw Community Health Organization (III)OH: Center for Families & Children (I)OH: Community Support Services (IV)OH: Greater Cincinnati Behavioral Health Services (III)OH: Shawnee Mental Health Center (I)OH: Southeast Inc. (I) WV: Prestera Center for Mental Health Services (III)

Northeast & Mid-Atlantic Region (5)

CT: Bridges...A Community Support System (I)

CT: Community Mental Health Affiliates (III)

MA: Community Healthlink ,Inc (III)MD: Family Services, Inc (III)ME: Community Health & Counseling

Services (III)NH: Community Council of Nashua (I)NJ: Care Plus NJ (I)NJ: Catholic Charities, Diocese of

Trenton (III)NY: Bronx-Lebanon Hospital Center

(III)NY: Fordham Tremont CMHC (III)NY: ICD-International Center for the

Disabled (II)NY: Postgraduate Center for Mental

Health (III)NY: VIP Community Services (I)PA: Horizon House (III)PA: Milestone Centers (II)RI: Kent Center for Human &

Organizational Development (III)RI: The Providence Center (II)

SAMHSA PBHCI Grantees

Integrated health care“…in essence integrated health care is the

systematic coordination of physical and behavioral health care. The idea is that physical and behavioral health problems often occur at the same time. Integrating services to treat both will yield the best results and be the most acceptable and effective approach for those being served.” Hogg Foundation for Mental Health, Connecting Body & Mind: A Resource Guide to Integrated Health Care in Texas and the U.S., www.hogg.utexas.edu

11

Consumers’ take on integration“Around the time that my bipolar condition was identified, I

was diagnosed with kidney disease. Between the two disorders, it was a pretty upsetting time in my life… My doctors, dialysis clinic staff, and mental health case manager are well connected. They take a team approach, and they each check on the status of my health... Today I have control over my health; it doesn’t have control of me. The coordinated care allows me to feel like I can go out and be a part of the community.” – Cassandra McCallister, Board Member, Washtenaw Community Health Organization, Ypsilanti, MI

12

PC/BH Partnerships

Primary Care and Behavioral Health

It goes together like Peanut Butter and

Jelly!

Communication with Your Partners“The Four Agreements,” Don Miguel Ruiz • Be impeccable with your words. Clarify your partnership’s goal and

recognize that you have created a process that requires constant nurturing and communication.

• Don’t take anything personally. Disagreements will occur. Learn to manage the process, not the personality, and recognize and understand your differences.

• Don’t make assumptions. Involve both boards, schedule weekly administrative meetings, hold regular treatment team meetings, communicate between team meetings, and create a specialized data collection position.

• Do your best. Involve state and local stakeholders, seek training for staff in care coordination, bring in outside experts such as CIHS for guidance, and engage other organizations that do similar work.

The Role of LeadershipMain point: Leaders who employ research informed approaches are more likely to activate the organization to support a change initiative:

Communicating for buy in (what is the message? Who delivers the message? How do we know if the workforce understands and values the message? What practical actions can the workforce take that promotes engagement of consumers?

How does an organization insure that the workforce supports the aims of the integration initiative?

How does the organization insure that the primary care partners understand, value and act in ways that are likely to engage consumers.

16

17

8.Make the

Changes Stick

7. Don’t Let Up

6. Short Term Wins

5. Empower Action

4. Build the Right Team

3. Communicate for Buy In

2. Get the Vision Right

1. Build a Sense of UrgencyBased on the work of J. Kotter (2002) The Heart of Change.

Steps leaders take to successfully implement change

Workforce Considerations

Administrative Staff and Board of Directors – data including prevalence, clinical and productivity outcomes

Clinical Team – screening, clinical protocols, motivational interviewing, how to deal with upset patients smoothly, effectively, empathetically

Behavioral Health Clinicians – UMass training, motivational interviewing, Psychiatric Consultation

Front Desk, Security - Mental Health First Aid

The Right Temperament

Persistence

Creativity and flexibility

Enthusiasm for learning

Strong patient advocate

Willingness to be interrupted

Ability to work in a team

Health Homes

22Achieving NCQA Recognition as a Patient-Centered Medical Home

RI Statewide Learning Collaborative February 5, 2011

Focus on Behavioral Health

Incorporating attention to behaviors affecting health, mental health and substance abuse

• PCMH 1: Enhance Access and Continuity– Comprehensive assessment includes depression screening,

behaviors affecting health and patient and family mental health and substance abuse

• PCMH 3: Plan and Manage Care– One of three clinically important conditions identified by the

practice must be a condition related to unhealthy behaviors (e.g. obesity) or a mental health or substance abuse condition

– Practice must plan and manage care for the selected condition• PCMH 4: Provide Self-Care and Community Resources

– Self-care support includes educational and community resources and adopting healthy behaviors

• PCMH 5: Track and Coordinate Care– Tracks referrals and coordinates care with mental health and

substance abuse services• PCMH 6: Measure and Improve Performance

– Preventive measures include depression screening

Behavior Health Change

Why Do People Change?

Individuals change voluntarily when they. . .

Become interested in or concerned about the need for change

Become convinced that the change is in their best interests or will benefit them more than cost them

Organize a plan of action that they are committed to implementing

Take the actions that are necessary to make the change and sustain the change

Person-Centered Skills: The BasicsUtilize O.A.R.S.

• Ask Open-ended questions (not short-answer, yes/no, or rhetorical)

• Affirm the person/commitment positively on specific strengths, effort, intention

• Reflect feelings and change talk• Summarize topic areas related to

changing

Operations

Formal Business Process Analysis Supports Clear, Precise, Accessible Communication

• Step-by-step financial, clinical and practice management activities

• Promotes cross-discipline understanding of each step

• Connects multiple dimensions –billing, data collection and reporting, clinical services, practice management, etc.

• “Requirements Traceability Matrix” - what you do and why you do it

Cleaned up

Analysis Examples

• Timing • How long are activities within the process taking? • How much time passes between activities? • How long are the patient contact intervals within Intake? Between

Intake and Re-assessment?

• Billing • What are the billable/non-billable events? • Is there a way you can make non-billable events billable?• How do these events match up to the appropriate license/credential of

the role? Are you maximizing the amount of reimbursement?

• Role License and Credentials• Where and how are you meeting credentialing requirements?• Do they match the billable activities?

Finance and Billing

Billing and Coding Infrastructure

• Staffing – Sample of needed expertise• Chief Financial Officer• Payables and Receivables staff• Claims Processers

• Knowledge of Payer Requirements• Private Payers• Medicaid• Medicare

• Technology supports• Accurate, good documentation of services

The Health and Behavior Assessment/Intervention Codes (96150 - 96155)

• Approved CPT Codes for use with Medicare right now• Some states are using them now for Medicaid• Behavioral Health Services “Ancillary to” a physical health

diagnosisDiabetesCOPD Chronic Pain

Maximizing Who Can Bill, for What, and By Whom – Interim Billing Worksheets• Point in time review of each states Medicaid program on what may or may

not be reimbursable in your state for integration using currently available codes

• Point in time review of Medicare reimbursement• Link CPT, Diagnostic Code and Credential • One of many tools – a place to start the conversation and billing locally

and in a state• Do not GUARANTEE you will be paid based on the worksheet

Worksheets Available at:

www.integration.samhsa.gov

The resources and information needed

to successfully Integrate primary

and behavioral health care

Laura Galbreath, MPPOnline: integration.samhsa.govPhone: 202-684-7457, ext 231Email: laurag@thenationalcouncil.org